Infuze Application Form - Infuze Funding

BUSINESS INFORMATION

Legal Corporate Name*

DBA

Physical Address*

Telephone #*

Fax #

Federal Tax ID*

Date Business Started

Length of Ownership

Website

Email*

Type of Entity (check one)*

Sole Proprietorship
Partnership
Corporation
LLC
Other

Type of Business (check all that apply)

Retail
MO/TO
Wholesale
Restaurant
Supermarket
Other

Product/Service Sold

MERCHANT/OWNER INFORMATION

Corporate Officer/Owner Name*

Title

Ownership %

Address*

SSN*

Date of Birth*

Home #*

Cell #

PARTNER INFORMATION

Partner Name

Title

Ownership %

Address

SSN

Date of Birth

Home #

Cell #

BUSINESS PROPERTY INFORMATION

Business Landlord or Business Mortgage Bank

Contact Name and/or Account #

Phone #

BUSINESS TRADE REFERENCES

(Please list at least 3 trade suppliers.)

Business Name

Contact, Account # or Fax #

Phone #

Business Name

Contact, Account # or Fax #

Phone #

Business Name

Contact, Account # or Fax #

Phone #

OTHER INFORMATION

Credit Card Processing Terminal(s)/Software Model

Number of Terminals

Avg. Monthly Credit Card Volume

Avg. Monthly Gross Sales Volume

Requested Advance Amount

Do you Accept (please check all that apply)

Visa/MasterCard
Amex
Discover
Debit
EBT

Prior/Current Cash Advance Company (if applicable)

Balance

Bank Statements

Drop files here or

Max. file size: 256 MB.

Please attach 3 months bank statements and 3 months merchant statements (if you accept credit cards).

Did you upload at least 3 months bank statements?*

Yes
No
Start-up/ Don't have any

Disclaimer

Applicant(s) authorizes Infuze Funding and its assigns, agents, banks or financial institutions to obtain an investigative or consumer report from a credit bureau or a credit agency and to investigate the references given on any other statement or data obtained from applicant.

Signature*

Date*